Understanding Breast Cancer Awareness, Perceptions, and Screening Practices Among the Population of Jazan, Saudi Arabia: A Cross-Sectional Study

Background: Breast cancer represents a significant global health challenge, with Saudi Arabia experiencing high incidence rates, particularly among females. Early detection through screening methods such as mammography and breast self-examination offers promise in reducing mortality rates. However, participation in screening remains suboptimal, posing a barrier to effective cancer control. In regions like Jazan, situated in southwestern Saudi Arabia, comprehensive studies on breast cancer awareness and screening practices are lacking. Methods: This cross-sectional study conducted in Jazan, Saudi Arabia, aimed to comprehensively assess breast cancer awareness, perceptions, and screening practices among the local population. An online survey platform was utilized to reach individuals aged 18 years or older residing in Jazan. Recruitment efforts utilized social media platforms, community networks, and local organizations to ensure diverse representation across socioeconomic backgrounds, education levels, and geographical locations. A meticulously designed questionnaire captured demographic information, breast cancer awareness, knowledge, health-seeking behaviors, screening practices, and barriers to mammogram screening. Participants provided electronic informed consent before self-administering the questionnaire. Results: The study conducted in Jazan, Saudi Arabia, encompassed 533 participants, predominantly young to middle-aged individuals. Most participants were Saudi nationals (97.6%), employed in the government sector (55.7%), and resided in urban areas (61.0%). Awareness of breast cancer was high, with 98.1% having heard of the disease. However, perceptions of age of onset and prevalence varied. While participants showed varied awareness of breast cancer warning signs and risk factors, family history was a commonly agreed-upon risk factor (54.4%). Health-seeking behavior for breast cancer symptoms varied, with nipple changes prompting the most immediate medical attention (36.4%). Although most participants were aware of self-breast examination (84.6%) and mammograms (56.7%), utilization rates were suboptimal, with barriers including fear (79.7%) and embarrassment (71.5%) hindering mammogram screening uptake. Conclusion: This study provides insights into breast cancer awareness and screening practices among participants in Saudi Arabia. While awareness of breast self-examination and mammography is high, disparities in screening service access persist due to barriers like fear and embarrassment. Addressing these barriers through culturally sensitive interventions and collaborative efforts is crucial for enhancing screening uptake and promoting health equity.


Introduction
Breast cancer stands as one of the most pervasive and lethal cancers globally, exerting a significant toll on public health systems and individual lives.The World Health Organization (WHO) identifies female breast cancer as among the top three most common cancers worldwide, with a staggering 2.3 million cases reported in 2020 alone [1].Tragically, breast cancer ranks as the leading cause of cancer-related deaths among females, claiming the lives of approximately 685,000 women globally in the same year [1].Within the context of Saudi Arabia, breast cancer holds a particularly notable position, representing approximately 28% of all cancers affecting Saudi females and 13% of all cancers affecting both sexes in 2016 [2].
While breast cancer poses a formidable threat, early detection through screening tests such as mammography and breast self-examination offers a beacon of hope.The WHO underscores the potential of mammography screening in high-resource settings to reduce mortality by up to 20%, while early detection can dramatically elevate the chances of recovery to 90% or higher [3].Despite the proven efficacy of screening modalities, participation rates among women remain below recommended levels, posing a formidable challenge to effective cancer control efforts [4].
In the Middle Eastern context, including Saudi Arabia, research on breast cancer awareness and screening practices has emerged, yet comprehensive studies assessing these aspects, particularly in regions like Jazan, remain scarce [5][6][7].The Jazan region, nestled in the southwestern part of Saudi Arabia, presents a unique landscape characterized by diverse sociocultural dynamics and healthcare access challenges.Despite the prevalence of breast cancer in the region, there exists a notable gap in cross-sectional studies evaluating awareness and screening practices among the female population, particularly among key demographics such as female school teachers, who wield significant influence in disseminating health-related knowledge.
This study endeavors to bridge this gap by conducting a comprehensive assessment of knowledge, attitudes, and practices regarding breast cancer and radiological screening tests among female populations in Jazan City.Moreover, the research aims to identify factors influencing the uptake of breast cancer screening tests, thereby laying the groundwork for targeted interventions aimed at enhancing awareness and promoting proactive health-seeking behaviors.

Study design and setting
This cross-sectional study was conducted in Jazan, Saudi Arabia, with the aim of comprehensively assessing breast cancer awareness, perceptions, and screening practices among the local population.Data collection commenced in January 2024 and continued through an online survey platform for four weeks.

Participant recruitment
Participants were recruited using multifaceted approaches to ensure broad representation.Leveraging social media platforms, community networks, and local organizations, invitations to participate were extended to individuals aged 18 years or older residing in Jazan.The recruitment process emphasized inclusivity, targeting diverse socioeconomic backgrounds, educational levels, and geographical locations within the region.

Data collection instrument
A meticulously designed questionnaire was crafted to capture the nuanced aspects of breast cancer awareness, attitudes, and behaviors pertinent to the local context.Hosted on a user-friendly online survey platform, the questionnaire comprised multiple sections covering demographic information, breast cancer awareness and knowledge, health-seeking behaviors, screening practices, and barriers to mammogram screening.The instrument underwent rigorous piloting and validation procedures to ensure clarity, relevance, and cultural appropriateness for the study population.

Data collection procedure
Upon accessing the survey link, participants were presented with an electronic informed consent form outlining the study's purpose, confidentiality measures, and their rights as participants.Following consent, participants self-administered the questionnaire at their convenience, providing responses to the structured items.Data quality was ensured through validation checks within the online survey platform and doubledata entry verification for online-based surveys.

Study variables
The study variables encompassed a wide range of demographic characteristics, including age, gender, education level, monthly income, occupation, nationality, residence type, and marital status, to capture the diverse sociodemographic profile of the population.Additionally, a comprehensive assessment of breast cancer awareness was conducted, exploring personal and family history of the disease, knowledge of the age of onset and prevalence, perceptions of risk factors and warning signs, immediate health-seeking behaviors for symptoms, awareness and practices related to screening methods such as self-breast examination and mammograms, and identification of barriers hindering mammogram utilization.

Data analysis
Data collected from the online survey platform were exported to a secure electronic database for analysis.Descriptive statistics, specifically frequencies and percentages, were computed using IBM SPSS Statistics version 25 (IBM Corp., Armonk, NY) to summarize demographic characteristics and study variables.These descriptive analyses provided insights into the distribution and composition of the study sample across categorical variables.

Ethical considerations
The study adhered to ethical principles and guidelines for research involving human participants.Institutional Review Board approval was obtained from the Saudi Oncology Health Economics Expert Group.Measures were implemented to safeguard participants' confidentiality, privacy, and voluntary participation throughout the study.Additionally, informed consent was obtained from all participants prior to their involvement in the study.

TABLE 3: Awareness and recognition of breast cancer warning signs (N=533)
Data are presented as frequency (n) and percentage (%), representing the number and proportion of participants in each category, respectively.

Breast cancer screening awareness and practices
Participants' awareness and practices regarding breast cancer screening varied.The majority had heard of the self-breast examination (451, 84.6%), with a significant number initiating the examination between the ages of 18 and 34 years (225, 42.2%).However, 280 participants (52.5%) reported never or rarely conducting self-exams.Regarding mammograms, most participants had heard of them (302, 56.7%), and the majority had access to mammogram centers (370, 69.4%).However, only a minority had undergone a mammogram previously (114, 21.4%), with 390 participants (73.2%) expressing willingness to undergo mammogram screening (Table 6).

Discussion
Our study sheds light on the landscape of breast cancer awareness, screening practices, and associated factors among participants in Saudi Arabia, offering valuable insights into the current state of breast health knowledge and behaviors in the region.Building upon existing literature, we highlight key findings that elucidate the prevalence of breast cancer awareness, disparities in screening uptake, and barriers to healthcare-seeking behavior among our study cohort.
The literature underscores the critical role of breast screening in detecting malignancies at early stages, thereby reducing morbidity and mortality rates associated with breast cancer [8][9][10].Previous studies have highlighted the efficacy of healthcare provider-led initiatives in promoting routine breast examinations and increasing awareness of self-breast examination, clinical breast examination, and mammography [11].Our study aligns with these findings, revealing a substantial awareness of breast self-examination and mammography among participants.However, despite widespread awareness, disparities persist in access to screening services, echoing findings from studies conducted across different cultural contexts [12].
Despite the availability of screening modalities, various barriers hinder screening uptake and healthcareseeking behavior.Fear, embarrassment, privacy concerns, and lack of confidence emerge as significant impediments to timely screening and healthcare utilization, consistent with findings from studies conducted across different cultural contexts [13,14].These findings underscore the need for culturally sensitive interventions and patient-centered approaches to address barriers and enhance screening adherence.
Healthcare professionals play a pivotal role in promoting breast cancer awareness and facilitating informed decision-making among patients.The literature emphasizes the importance of provider-patient communication, patient education, and community engagement in improving screening uptake and health outcomes [15].Our study underscores the need for concerted efforts to equip healthcare professionals with the knowledge and resources to effectively communicate with patients and address misconceptions surrounding breast cancer screening.
Moving forward, future research should prioritize addressing knowledge gaps, enhancing access to screening services, and evaluating the effectiveness of interventions tailored to specific population groups.
Longitudinal studies are warranted to assess the impact of educational campaigns, policy initiatives, and structural interventions on screening behaviors and breast cancer outcomes [15,16].Moreover, collaborations between stakeholders, including healthcare providers, policymakers, advocacy groups, and community organizations, are essential to developing comprehensive breast cancer control programs and promoting health equity.

TABLE 1 : Demographic profile of study participants (N=533)
Among the study cohort, a negligible percentage reported personal breast cancer history (4, 0.8%), while a notable proportion had a family history of breast cancer (155, 29.1%).Almost all participants had heard of breast cancer (523, 98.1%), with varying perceptions of its age of onset and prevalence.Regarding age of onset, the majority believed it could occur at any age (188, 35.3%) or at 30 and above (190, 35.6%).However, a significant proportion was unsure (260, 48.8%) about the age of onset.Similarly, perceptions regarding breast cancer prevalence varied, with sizable proportions believing it to be one in nine (176, 33.0%) or one in three (108, 20.3%) (Table2).
Data are reported in terms of frequency (n) and percentage (%).Frequency represents the number of participants in each category, while percentages indicate the proportion of participants in each category.Breast cancer awareness and history

TABLE 6 : Knowledge and practices regarding breast cancer screening (N=533)
Data are presented as frequency (n) and percentage (%), indicating the number and proportion of participants in each category, respectively.

TABLE 7 : Barriers to undergoing mammogram screening (N=533)
Data are presented as frequency (n) and percentage (%), indicating the number and proportion of participants experiencing each barrier.